Ophthalmology

History and Examination

 History
• History should allow for recording important
information that could affect patient’s
diagnosis and treatment

• Components of history are essentially the

same as those of any general medical history,
except that ophthalmic aspect are emphasized
 Components
• (Identification)
• Chief complaint
• Present illness
• Past ocular history
• General medical and surgical history
• Family and social history
 Identification
-Name
-Age
-Sex
-Occupation
-Level of education
-Address and telephone number
-Race
 Chief complaint
• Patient’s main complaint(s) should be recorded in
patient’s words( non technical)

• Avoid medical terms that suggest premature

diagnosis

• If the patient is troubled by more than one

symptom or problem then the chief complaints
should be more than one
 Present illness
• Time and manner of onset(gradual or sudden)

• Severity (improvement, same or worsening)

• Influences (what precipitated the condition

know when refractive prescription last changed).
Consistency and temporal variations(intermittence
or seasonal, exacerbations or remissions
• Laterality
• Clarification (to clarify what the patient means
by certain complaints)
• Documentation (old records, photographs can
help eg ptosis, proptosis, facial nerve palsy
 Past ocular history
• Uses of eyeglasses or contact lenses
• Use of ocular medication in the past
• Ocular surgery (including laser
• Ocular trauma
• History of amblyopia (lazy eye) or of ocular
patching in childhood
• If positive answer ask why, how, where and by
whom as applicable
• Ocular medication: Important because it gives
an idea on how a patient responded to the prior
treatment
• Can affect present status of the patient(toxic
and allergic reactions to topical and
preservatives sometimes resolve slowly
• Prior and current medications should be
recorded including dosage, frequency and
duration and herbal, home made remedies
 General medical and surgical history

• Medical and surgical problems should be

recorded along with approximate dates of
onset, medical and surgical treatment
• Ask about diabetes, hypertension, malignancy,
• As well as dermatologic, cardiac, renal,
hepatic, pulmonary, gastrointestinal, central
nervous system and autoimmune
collagen(including arthritic) diseases
• Sexual history including previous sexually
transmitted diseases can be pertinent in some
situations
• For pediatric patient ,prenatal care, drugs
used, labor progress, delivery, prematurity and
neonatal period informations are recorded
• Systemic medication : Can cause ocular,
preoperative, intraoperative and
postoperative problems and give clues to
systemic disorders the patient might have eg
aspirin and other anticoagulant agents.
• Some medicines such amiodarone, systemic
steroids, phenothiazines and
hydroxychloroquine can have ocular toxicity
• Allergies : It is important to ask about and record the
nature of reactions (itching, rashes, wheezing and
cardio respiratory collapse) in order to distinguish
them from side effects
• Ask about environmental agents(atopy) that may
result in atopic dermatitis, allergic asthma, allergic
rhinitis conjunctivitis, vernal conjunctivitis
• Before injecting dye for fluorescein or other
angiography ask for previous injection and if reaction
or not
 Social history
• May reveal tobacco, alcohol use, drug abuse,
tattoos, piercing environmental factors and
occupation
• Questioning should be pursued in a
nonjudgmental way with sensitivity and
respect for privacy
 Family history
• Along with family member wearing glasses ,one
can ask about corneal disease, glaucoma,
cataract, retinal disease or other heritable ocular
conditions
• Atopy, thyroid disease, diabetes mellitus ,certain
malignancy can be considered in a familial context
• Inability of the patient to provide family
information should be recorded as incomplete
and not negative
 Examination
• Visual acuity examination (determined with
and without current correction if any, near
and at distance)
• Determination of best corrected visual acuity
• Ocular alignment and motility examination
• Pupillary examination
• Visual field examination
• Examination of external eye and adnexa
• Examination of the anterior segment
• Tonometry to determine intraocular pressure
• Posterior segment examination
 Preliminary to eye examination
• It is done to record any gross abnormality by
using torch light
• Position and size of eye balls and orbital
socket.
• Position and size of eye lids and its margins
and lashes.
• Surface of cornea, its shape,size, opacities.
• Position and color of Iris.
• Ocular movement.
• Pupillary action, size-dilated or not dilated.
• Lens clear or opacity, aphakia or
pseudophakia.
 Preliminary vision assessment
• It is done for finding out the existing vision .
• Check vision monocularly unaided and aided.
• Make sure whether patients is comfortable
with present glass or not.
• Decide whether the refraction is needed or
not
 Objective refraction
• It is done by streak retinoscope
• To determine objectively the actual refractive error of
patients.
• It is done monocularly by trial lens method
• It include following steps
– Positioning and alignment of patients.
– Maintained the proper working distance
– Observing the retinal reflex (with or against movement.
– Finding the neutrality point using the appropriate lens
 Subjective refraction
• Verification of findings obtained from
retinoscopy with patients
• Always proceed the subjective refraction
monocularly and also check the binocular
comfortness
• Confirm the unaided vision first and proceed
the lens accordingly
• Find out the spherical improvement first to
avoid unwanted cylinder
• Add cylinder to correct the remaining.
• Apply supplementary test to confirm the final
prescription
 Indications for auto refraction
• One who suspected to have high power in
retinoscopy
• The uncooperative patients while doing
retinoscopy
• One who comes for glass first time particularly
children
Indication of Cycloplegic refraction
• In any patients under 15 years of age
• In hyperopic patients up to 35 years especially if
symptomatic
• In pre and early presbyopia especially if glasses
have never been worn previously
• If refraction yields variable results especially in
under 50 years
• Patients who tend to accommodate during
refraction
• Whenever patent’s symptoms are disproportionate
with manifest refractive error or if patient’s
symptoms suggest problem of accomodation
• Obvious or suspected extraocular muscle
imbalance
• If the examiner has to rely on the retinoscope to
give all refractive informations
• Bilateral refractive asymmetry or if binocular good
balance can not be achieved
 References
• Practical ophthalmology
• Clinical refraction procedure